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Acute Heart Failure and Pulmonary Oedema

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💔 Cardiogenic Pulmonary Oedema (CPO) is a medical emergency. Often triggered by STEMI, arrhythmia, or mechanical failure. Always exclude these early. A simple bedside echo is invaluable.

💔 Emergency Management: Cardiogenic Pulmonary Oedema (CPO)
🪑 Position → Sit upright, legs dependent 🫁 Oxygen → Maintain sats >92% (88–92% if COPD); CPAP if hypoxic 💧 Diuretics → Furosemide 40–80 mg IV bolus 💉 Opiates → Morphine 2.5–5 mg IV slow + antiemetic 💊 Nitrates → GTN spray; IV infusion if SBP >110 mmHg 🫀 Arrhythmias/STEMI → Treat AF/VT; urgent PCI if STEMI 🔌 Advanced Support → CPAP/NIV, balloon pump, dialysis if needed 💡 Mnemonic: LMNOP → Lasix (furosemide), Morphine, Nitrates, Oxygen, Position

💔 Emergency Management: Cardiogenic Pulmonary Oedema (CPO)

🪑 Position → Sit upright, legs dependent
🫁 Oxygen → Maintain sats >92% (88–92% if COPD); CPAP if hypoxic
💧 Diuretics → Furosemide 40–80 mg IV bolus
💉 Opiates → Morphine 2.5–5 mg IV slow + antiemetic
💊 Nitrates → GTN spray; IV infusion if SBP >110 mmHg
🫀 Arrhythmias/STEMI → Treat AF/VT; urgent PCI if STEMI
🔌 Advanced Support → CPAP/NIV, balloon pump, dialysis if needed

💡 Mnemonic: LMNOP → Lasix (furosemide), Morphine, Nitrates, Oxygen, Position

📋 Initial Management (Detailed)
Position & Oxygen Sit upright with legs dependent. Oxygen to maintain sats >92% (88–92% in COPD). Continuous ECG and BP monitoring. Diuretics Furosemide 40–80 mg IV (repeat if needed). Opiates Morphine 2.5–5 mg IV slow (or Diamorphine) + antiemetic. Nitrates GTN spray sublingual. IV nitrate infusion if SBP >110 mmHg or hypertensive. Non-Invasive Ventilation CPAP 5–10 cmH₂O if hypoxic/distressed despite O₂. Arrhythmias Atrial fibrillation → Digoxin, Amiodarone, or DC cardioversion. Ventricular tachycardia → Amiodarone or DC shock. STEMI / Mechanical Causes STEMI → PCI or thrombolysis. Papillary rupture / VSD → balloon pump + urgent surgery. Aortic stenosis/regurgitation → urgent cardiology review. Renal Support Dialysis/ultrafiltration if oliguric with renal failure.

📋 Initial Management (Detailed)

Position & Oxygen

Sit upright with legs dependent.
Oxygen to maintain sats >92% (88–92% in COPD).
Continuous ECG and BP monitoring.

Diuretics

Furosemide 40–80 mg IV (repeat if needed).

Opiates

Morphine 2.5–5 mg IV slow (or Diamorphine) + antiemetic.

Nitrates

GTN spray sublingual.
IV nitrate infusion if SBP >110 mmHg or hypertensive.

Non-Invasive Ventilation

CPAP 5–10 cmH₂O if hypoxic/distressed despite O₂.

Arrhythmias

Atrial fibrillation → Digoxin, Amiodarone, or DC cardioversion.
Ventricular tachycardia → Amiodarone or DC shock.

STEMI / Mechanical Causes

STEMI → PCI or thrombolysis.
Papillary rupture / VSD → balloon pump + urgent surgery.
Aortic stenosis/regurgitation → urgent cardiology review.

Renal Support

Dialysis/ultrafiltration if oliguric with renal failure.

💡 Mnemonic: LMNOP = Lasix (Furosemide), Morphine, Nitrates, Oxygen, Position upright.

📖 About

CPO = acute left ventricular dysfunction → pulmonary venous hypertension → alveolar flooding.
Rapidly leads to respiratory failure ± cardiogenic shock.
30-day mortality ~15% if NT-proBNP >5000 ng/L.
LV systolic function strongly influences prognosis.

⚖️ Pathophysiology

Normally: Plasma oncotic pressure (~25 mmHg) holds water in; Pulmonary capillary pressure (~7–12 mmHg) pushes fluid out.
If PCP > POP → alveolar oedema → hypoxia, ↑ work of breathing.

🔎 Aetiology

Poor systolic function (e.g. MI).
Poor diastolic function (HFpEF).
Valve lesions (MR, AR, AS).
Arrhythmias (AF, VT, bradycardia).
Hypertension, myocarditis, cardiomyopathy.
Fluid overload (transfusion, renal failure).

❓ Precipitating Causes

Cause	Clues	Diagnostics
MI	Chest pain, diaphoresis	ECG, troponin, echo
AF	Palpitations, irregular pulse	ECG, echo
HTN	Headache, chest pain	BP, LVH on echo
Valvular disease	Murmur, dyspnoea	Echo, Doppler
PE	Pleuritic pain, haemoptysis	CTPA, D-dimer
Sepsis	Fever, hypotension	Blood cultures, lactate
Drug/alcohol	Recent change	Medication review

📊 Clinical: Left vs Right HF

Left-sided: Orthopnoea, PND, bibasal creps, “bat-wing” CXR.
Right-sided: Raised JVP, hepatomegaly, ascites, oedema.
Often coexist → congestive HF.

📌 NYHA Functional Classes

Class	Symptoms
I	No limitation; ordinary activity tolerated.
II	Slight limitation; ordinary activity causes dyspnoea/fatigue.
III	Marked limitation; less than ordinary activity causes symptoms.
IV	Symptoms at rest; unable to tolerate activity.

🧪 Investigations

Bedside: ECG, SpO₂, ABG.
Bloods: FBC, U&E, LFT, TFT, Troponin, NT-proBNP.
Imaging: CXR (bat-wing, Kerley B lines), Echo (EF, valves).
Advanced: MRI, SPECT/PET, Angio.

⚡ Complications

Resp failure (Type 1 → Type 2).
Arrhythmias (AF, VT, SCD).
Renal failure, hepatic congestion.
Electrolyte imbalance (Na⁺, K⁺).
VTE, cachexia, frailty.

💊 Ongoing Management

Diuretics: Loop (Furosemide, Bumetanide).
ACEi/ARBs: Ramipril, Enalapril.
Beta-blockers: Bisoprolol, Carvedilol.
Aldosterone antagonists: Spironolactone, Eplerenone.
Other: Digoxin, Ivabradine, Amiodarone.
Advanced: CRT, LVAD, transplant.

📉 Prognosis

HF prognosis worse than many cancers.
EF <35% = poor marker.
NT-proBNP correlates with survival.
Consider palliative care in end-stage disease.

📚 References

Cases — Acute Heart Failure & Pulmonary Oedema

Case 1 — Hypertensive Emergency 💥: A 72-year-old man with untreated hypertension presents acutely breathless at night, unable to lie flat. Exam: BP 210/110, tachypnoea, widespread crackles, S3 gallop. CXR: bilateral perihilar “bat-wing” shadowing. Diagnosis: Acute pulmonary oedema triggered by hypertensive crisis. Acute Management: Sit upright, oxygen, IV furosemide, IV GTN infusion, morphine if distressed, strict BP control. Monitor U&Es and fluid balance.
Case 2 — Acute MI Complication ❤️: A 64-year-old man presents with acute chest pain followed by severe dyspnoea. Exam: hypotension, crackles to mid-zones, raised JVP, cool peripheries. ECG: anterior STEMI. Echo: severe LV systolic dysfunction. Diagnosis: Acute cardiogenic pulmonary oedema secondary to MI. Acute Management: Sit upright, O₂, IV diuretics, cautious opioids; urgent PCI for MI; inotropes or mechanical support (IABP) if shock persists.
Case 3 — Acute Decompensation in Chronic HF 🌀: A 78-year-old woman with known HFrEF (EF 30%) presents with sudden worsening breathlessness after a chest infection. Exam: tachypnoeic, bibasal crackles, elevated JVP, peripheral oedema. BNP elevated, CXR: pulmonary congestion. Diagnosis: Acute decompensated heart failure with pulmonary oedema, triggered by infection. Acute Management: Sit upright, O₂, IV furosemide; treat infection (antibiotics); optimise chronic therapy (ACEi, beta-blocker, spironolactone) once stable.

Teaching Commentary 🧠

Acute heart failure with pulmonary oedema is a medical emergency. - Pathophysiology: raised LV end-diastolic pressure → pulmonary venous congestion → alveolar fluid → hypoxia. - Precipitants: MI, arrhythmias, hypertensive crisis, infection, fluid overload, non-compliance. - Clinical: severe breathlessness, orthopnoea, crackles, frothy pink sputum, gallop rhythm. - Acute management (“PODMAN”): Position upright, Oxygen, Diuretics (IV loop), Morphine, Afterload reduction (nitrates), Non-invasive ventilation if hypoxic. Long-term: optimise HF therapy (ACEi/ARNI, beta-blockers, MRA, SGLT2 inhibitors); lifestyle and fluid restriction; device therapy (CRT, ICD) in select patients.

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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